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Patel KK, Shah JJ, Feng L, Lee HC, Manasanch EM, Olsem J, Morphey A, Huo XJ, Thomas SK, Bashir Q, Qazilbash MH, Weber DM, Orlowski RZ. Safety and Efficacy of Combination Maintenance Therapy with Ixazomib and Lenalidomide in Patients with Posttransplant Myeloma. Clin Cancer Res 2022; 28:1277-1284. [PMID: 34992070 PMCID: PMC9365361 DOI: 10.1158/1078-0432.ccr-21-3420] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/23/2021] [Accepted: 01/04/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE In this study, the addition of ixazomib to lenalidomide maintenance post-autologous stem cell transplant (ASCT) in 64 patients with newly diagnosed multiple myeloma was evaluated on the basis of the observed benefit of lenalidomide-only maintenance in prior studies. PATIENTS AND METHODS Patients were started on maintenance therapy with lenalidomide and ixazomib within 60-180 days of stem cell infusion. RESULTS Response rates deepened over time from baseline post-ASCT for 39 patients. The complete response (CR)/stringent CR rate was 43% and median overall survival was not reached with a median follow-up of 62 months (range, 25-82 months). Median PFS (mPFS) for all patients was 73 months and has not been reached for those with International Staging System (ISS) stage 1 disease. mPFS in 9 patients who had ISS stage 3 disease and 14 patients who had high-risk cytogenetics was 34 and 25 months, respectively. Twenty-two patients had progressive disease, while 19 patients continue to receive dual maintenance. The most common grade 3/4 adverse events included neutropenia, leukopenia, thrombocytopenia, lung infections, diarrhea, and maculopapular rash. Second primary malignancies occurred in 9 patients. Toxicity led to dose reductions in ixazomib and lenalidomide in 20 and 31 patients, respectively. Discontinuation of ixazomib due to toxicity occurred in 4 patients. Grade 1/2 neuropathy occurred in 22 patients and led to reduction or discontinuation of ixazomib in 2 patients. CONCLUSIONS The addition of ixazomib to lenalidomide maintenance demonstrated a better than expected PFS compared with historical data using lenalidomide alone and was safe and tolerable.
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Affiliation(s)
- Krina K. Patel
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas.,Corresponding Author: Krina K. Patel, Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030. Phone: 713-792-6662; Fax: 713-792-1897; E-mail:
| | | | - Lei Feng
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Hans C. Lee
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Elisabet M. Manasanch
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Jasper Olsem
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Ashley Morphey
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Xiao Jiao Huo
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Sheeba K. Thomas
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Muzaffar H. Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Donna M. Weber
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Robert Z. Orlowski
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas.,Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston Texas
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Impact of Induction with VCD vs. VRD on the Outcome of Patients with Multiple Myeloma After an Autologous Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2022; 28:307.e1-307.e8. [PMID: 35331973 DOI: 10.1016/j.jtct.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/01/2022] [Accepted: 03/17/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND nduction therapy with a triplet regimen, followed by high-dose therapy and autologous hematopoietic stem cell transplantation (auto-HCT) is the standard of care for newly diagnosed, transplant-eligible patients with multiple myeloma (MM). Bortezomib-dexamethasone with cyclophosphamide (VCD) or lenalidomide (VRD) are the most used induction regimens. However, previous studies comparing VCD and VRD showed disparate results. OBJECTIVES The goal of this retrospective study was to compare the "real world" results of VCD and VRD, in transplant-eligible MM patients outside of a clinical trial. METHODS/RESULTS We identified 322 patients who received VRD or VCD induction before auto-HCT at our institution. All patients received melphalan conditioning and single-agent lenalidomide maintenance therapy. Overall, 114 patients received VCD and 208 received VRD. The median age at auto-HCT was 61.9 years (range, 33.9-79.6), with 35.4% (114/322) of the cohort being 65 years or older. The overall response rate was 99.7% post-auto-HCT, with a significantly lower complete remission rate as the final response in the VCD compared to the VRD group (34% vs. 53%, p=0.001). However, there was no significant difference between the best response rate of VGPR or better in the VCD compared to the VRD group (92% vs. 85%, p=0.078). The median duration of ≥VGPR was 50.0 months (95%CI: 42.0-69.1) for both cohorts and there was no difference between VCD and VRD (p=0.769; HR, 0.95; 95% CI, 0.69-1.31). Median follow-up of survivors was 73 months. There was no difference in the relapse rate between VCD and VRD (p=0.749). Median progression-free survival (PFS) was 48.7 months in the VCD and 44.6 months in the VRD group (p=0.858). Median overall survival (OS) was 103.8 months with VCD and 101.7 months with VRD (p=0.891). At 5 years, the PFS and OS were 38.1% and 76.9% for the VCD group, respectively, and 40.7% and 74.6% for the VRD group, respectively. On multivariate analysis for OS in the entire cohort, R-ISS I and post-auto-HCT best response of stringent complete response (sCR)/CR emerged as significant predictors of superior OS. There was no impact of the type of induction regimen on the OS in the multivariate analysis. CONCLUSIONS Induction therapy with VCD compared to VRD was associated with a lower CR rate, but there was no difference in PFS or OS between the two regimens.
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153
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Karam D, Gertz M, Lacy M, Dispenzieri A, Hayman S, Dingli D, Buadi F, Kapoor P, Kourelis T, Warsame R, Hogan W, Kumar S. Impact of maintenance therapy post autologous stem cell transplantation for multiple myeloma in early and delayed transplant. Bone Marrow Transplant 2022; 57:803-809. [PMID: 35297404 DOI: 10.1038/s41409-022-01631-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 11/09/2022]
Abstract
Based on phase 3 trials, maintenance therapy after autologous stem cell transplantation (ASCT) has become the standard of care in multiple myeloma (MM). We examined the trends in maintenance therapy in a large group of patients (2530) transplanted at a single institution over two decades. Majority (n = 1958; 77%) had an ASCT within 12 months of diagnosis (early ASCT). Maintenance was employed in 39% of the patients; 42% among early ASCT and 30.5% among delayed ASCT. Most common maintenance approach was an IMiD (61%), followed by a PI (31%), or a PI + IMiD (4%). Patients with high-risk FISH received PI-based maintenance more frequently. The PFS was superior with maintenance (36 vs. 22 months, p < 0.001); 37 vs. 25 months for early ASCT (p < 0.001) and 29 vs. 17 months for delayed ASCT (p = 0.0008). OS from ASCT was higher with maintenance for the whole cohort at 93 vs. 73 months (p < 0.001). OS from diagnosis was also better for the whole cohort with maintenance therapy, 112 vs. 93 months (p < 0.001). The improvement in PFS and OS was seen in high-risk and standard risk disease. The experience with maintenance therapy post ASCT for myeloma in a non-clinical trial setting confirms the findings from the phase 3 trials.
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Affiliation(s)
- Dhauna Karam
- Department of Community Internal Medicine, Mayo Clinic Health System, Albert Lea, MN, USA
| | - Morie Gertz
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Martha Lacy
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Suzanne Hayman
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Francis Buadi
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rahma Warsame
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - William Hogan
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN, USA.
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154
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Brink M, Minnema MC, Visser O, Levin MD, Posthuma EFMW, Broijl A, Sonneveld P, van der Klift M, Roeloffzen WWH, Westerman M, van Rooijen CR, Geerts PAF, Zweegman S, van de Donk NWCJ, Dinmohamed AG. Increased mortality risk in multiple-myeloma patients with subsequent malignancies: a population-based study in the Netherlands. Blood Cancer J 2022; 12:41. [PMID: 35292622 PMCID: PMC8924210 DOI: 10.1038/s41408-022-00640-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/17/2022] [Accepted: 02/24/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mirian Brink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.
| | - Monique C Minnema
- Department of Hematology, Cancer Center, UMC Utrecht, Utrecht, The Netherlands
| | - Otto Visser
- Department of Registration, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Annemiek Broijl
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | | | - Matthijs Westerman
- Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | - Cleo R van Rooijen
- Department of Hematology, Medical Center Twente, Enschede, The Netherlands
| | - Paul A F Geerts
- Department of Hematology, Isala Hospital, Zwolle, The Netherlands
| | - Sonja Zweegman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Niels W C J van de Donk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Avinash G Dinmohamed
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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155
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Rivera Duarte A, Reece D, Li X, Xu W, Paul H, Masih-Khan E, Winter A, Tiedemann R, Prica A, Chen C, Trudel S, Kukreti V. Fixed duration vs. prolonged duration treatment after first line therapy in patients with systemic light chain amyloidosis. Amyloid 2022; 29:23-30. [PMID: 34519603 DOI: 10.1080/13506129.2021.1978423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The main objective of treatment in systemic light chain amyloidosis (AL amyloidosis) is to achieve the best hematological response. Deeper responses are associated with better organ responses and survival. In this study, we analysed the efficacy of prolonged duration treatment after first line in patients with AL amyloidosis. METHODS Retrospective analysis that included patients older than 18 years with AL amyloidosis. We excluded patients with more than 30% marrow plasmacytosis or concurrent multiple myeloma. Two cohorts identified accordingly if they received or not prolonged treatment after the first line. Survival analysis regarding progression free survival (PFS) and overall survival (OS) estimated with Kaplan-Meier and comparisons between groups with log-rank. RESULTS Thirty-eight patients were included in the analysis with a median age of 55 years. Twenty-one patients received prolonged duration treatment and 17 did not. In the prolonged duration group, after a median duration of 12 months, the median PFS was 58.8 months. In the fixed duration treatment group, PFS was 30.6 months. The difference was significant with p = .0045 favouring prolonged duration treatment. Organ response was sustained for a longer period in the prolonged duration treatment group. For OS, the difference was not significant. CONCLUSIONS Prolonged duration treatment in patients with systemic light chain amyloidosis correlated with better PFS and deeper organ responses. Prospective studies are needed to analyse this further.
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Affiliation(s)
- Alfonso Rivera Duarte
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Donna Reece
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Xuan Li
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Harminder Paul
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Esther Masih-Khan
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew Winter
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Rodger Tiedemann
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Anca Prica
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Christine Chen
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Suzanne Trudel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Vishal Kukreti
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
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156
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Muranushi H, Kanda J, Kobayashi M, Maeda T, Kitano T, Tsuji M, Ueda Y, Ishikawa T, Nohgawa M, Watanabe M, Imada K, Moriguchi T, Itoh M, Ohno H, Yonezawa A, Hirata H, Arima N, Asagoe K, Anzai N, Nagata K, Yasuno S, Kuwabara Y, Kitao H, Kim I, Kawagishi K, Ueshima K, Tominari S, Nakayama T, Yamashita K, Takaori-Kondo A. Bortezomib-cyclophosphamide-dexamethasone induction/consolidation and bortezomib maintenance for transplant-eligible newly diagnosed multiple myeloma: phase 2 multicenter trial. Hematology 2022; 27:239-248. [DOI: 10.1080/16078454.2022.2032915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hiroyuki Muranushi
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masayuki Kobayashi
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Hematology, Japan Baptist Hospital, Kyoto, Japan
| | - Takeshi Maeda
- Department of Haematology/Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshiyuki Kitano
- Department of Hematology, Medical Research Institute Kitano Hospital, Osaka, Japan
| | - Masaaki Tsuji
- Department of Hematology and Immunology, Otsu Red Cross Hospital, Otsu, Japan
| | - Yasunori Ueda
- Department of Haematology/Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Hospital Organization Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masaharu Nohgawa
- Department of Hematology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Mitsumasa Watanabe
- Department of Hematology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kazunori Imada
- Department of Hematology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | | | - Mitsuru Itoh
- Department of Hematology, Kyoto City Hospital, Kyoto, Japan
| | - Hitoshi Ohno
- Department of Hematology, Tenri Hospital, Tenri, Japan
| | - Akihito Yonezawa
- Department of Hematology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hirokazu Hirata
- Department of Hematology, Kansai Electric Power Hospital, Osaka, Japan
| | - Nobuyoshi Arima
- Department of Hematology, Medical Research Institute Kitano Hospital, Osaka, Japan
| | - Kohsuke Asagoe
- Department of Hematology and Oncology, Shiga General Hospital, Moriyama, Japan
| | - Naoyuki Anzai
- Department of Hematology and Oncology, Takatsuki Red Cross Hospital, Takatsuki, Japan
| | - Kayoko Nagata
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Yasuno
- Clinical Research Support Center, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Kuwabara
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Hiromi Kitao
- Department of Data Science, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Ihhwa Kim
- Department of Data Science, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Kiyomi Kawagishi
- Department of Data Science, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital, Kyoto, Japan
| | - Shinjiro Tominari
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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157
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Morè S, Corvatta L, Manieri VM, Saraceni F, Scortechini I, Mancini G, Fiorentini A, Olivieri A, Offidani M. Autologous Stem Cell Transplantation in Multiple Myeloma: Where Are We and Where Do We Want to Go? Cells 2022; 11:606. [PMID: 35203257 PMCID: PMC8870632 DOI: 10.3390/cells11040606] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/22/2022] Open
Abstract
The introduction of high-dose therapy in the 1990s as well as the development of drugs such as thalidomide, lenalidomide, and bortezomib in the 2000s led to an impressive improvement in outcome of patients with multiple myeloma (MM) eligible for autologous stem cell transplantation (ASCT). Clinical trials conducted in the first ten years of the twenty-first century established as standard therapy for these patients a therapeutic approach including induction, single or double ASCT, consolidation, and maintenance therapy. More recently, incorporating second-generation proteasome inhibitors carfilzomib and monoclonal antibody daratumumab into each phase of treatment significantly improved the efficacy of ASCT in terms of measurable residual disease (MRD) negativity, Progression Free Survival (PFS), and Overall Survival (OS). The availability of techniques such as multiparameter flow cytometry (MFC) and next-generation sequencing (NGS) for MRD assessment allowed the design of MRD-based response-adjusted trials that will define, in particular, the role of consolidation and maintenance therapies. In this review, we will provide an overview of the most recent evidence and the future prospects of ASCT in MM patients.
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Affiliation(s)
- Sonia Morè
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Laura Corvatta
- U.O.C. Medicina, Ospedale Engles Profili, 60044 Fabriano, Italy;
| | - Valentina Maria Manieri
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Francesco Saraceni
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Ilaria Scortechini
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Giorgia Mancini
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Alessandro Fiorentini
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Attilio Olivieri
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
| | - Massimo Offidani
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, 60126 Torrette, Italy; (S.M.); (V.M.M.); (F.S.); (I.S.); (G.M.); (A.F.); (A.O.)
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158
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Reinoso-Segura M, Caballero-Velázquez T, Herrera P, Patriarca F, Fanin R, Bruno B, Einsele H, Nahi H, Granell M, López-Corral L, Reguera JL, García-Cadenas I, Gahrton G, Pérez-Simón JA. Phase II trial of allogeneic transplantation plus novel drugs in multiple myeloma: effect of intensifying reduced intensity conditioning with bortezomib and adding maintenance treatment. Transplant Cell Ther 2022; 28:258.e1-258.e8. [DOI: 10.1016/j.jtct.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/05/2022] [Accepted: 01/30/2022] [Indexed: 10/19/2022]
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159
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Cowan AJ, Green DJ, Kwok M, Lee S, Coffey DG, Holmberg LA, Tuazon S, Gopal AK, Libby EN. Diagnosis and Management of Multiple Myeloma: A Review. JAMA 2022; 327:464-477. [PMID: 35103762 DOI: 10.1001/jama.2022.0003] [Citation(s) in RCA: 358] [Impact Index Per Article: 179.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Multiple myeloma is a hematologic malignancy characterized by presence of abnormal clonal plasma cells in the bone marrow, with potential for uncontrolled growth causing destructive bone lesions, kidney injury, anemia, and hypercalcemia. Multiple myeloma is diagnosed in an estimated 34 920 people in the US and in approximately 588 161 people worldwide each year. OBSERVATIONS Among patients with multiple myeloma, approximately 73% have anemia, 79% have osteolytic bone disease, and 19% have acute kidney injury at the time of presentation. Evaluation of patients with possible multiple myeloma includes measurement of hemoglobin, serum creatinine, serum calcium, and serum free light chain levels; serum protein electrophoresis with immunofixation; 24-hour urine protein electrophoresis; and full-body skeletal imaging with computed tomography, positron emission tomography, or magnetic resonance imaging. The Revised International Staging System combines data from the serum biomarkers β2 microglobulin, albumin, and lactate dehydrogenase in conjunction with malignant plasma cell genomic features found on fluorescence in situ hybridization-t(4;14), del(17p), and t(14;16)-to assess estimated progression-free survival and overall survival. At diagnosis, 28% of patients are classified as having Revised International Staging stage I multiple myeloma, and these patients have a median 5-year survival of 82%. Among all patients with multiple myeloma, standard first-line (induction) therapy consists of a combination of an injectable proteasome inhibitor (ie, bortezomib), an oral immunomodulatory agent (ie, lenalidomide), and dexamethasone and is associated with median progression-free survival of 41 months, compared with historical reports of 8.5 months without therapy. This induction therapy combined with autologous hematopoietic stem cell transplantation followed by maintenance lenalidomide is standard of care for eligible patients. CONCLUSIONS AND RELEVANCE Approximately 34 920 people in the US and 155 688 people worldwide are diagnosed with multiple myeloma each year. Induction therapy with an injectable proteasome inhibitor, an oral immunomodulatory agent and dexamethasone followed by treatment with autologous hematopoietic stem cell transplantation, and maintenance therapy with lenalidomide are among the treatments considered standard care for eligible patients.
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Affiliation(s)
- Andrew J Cowan
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Damian J Green
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Mary Kwok
- Seattle Cancer Care Alliance, Seattle, Washington
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Sarah Lee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - David G Coffey
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, Florida
| | - Leona A Holmberg
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Sherilyn Tuazon
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Now with Bristol Myers Squibb, Seattle, Washington
| | - Ajay K Gopal
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Edward N Libby
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
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Sidana S, Kumar S, Fraser R, Estrada-Merly N, Giralt S, Agrawal V, Anderson LD, Aljurf M, Banerjee R, Bashey A, Battiwalla M, Beitinjaneh A, Chakraborty R, Chhabra S, Dhakal B, Dholaria B, Hashmi S, Janakiram M, Lee C, Lekakis L, Murthy HS, Parrondo R, Wangjam T, Usmani S, Shah N, Qazilbash M, D’Souza A. Impact of Induction Therapy with VRD versus VCD on Outcomes in Patients with Multiple Myeloma in Partial Response or Better Undergoing Upfront Autologous Stem Cell Transplantation. Transplant Cell Ther 2022; 28:83.e1-83.e9. [PMID: 34781066 PMCID: PMC8900987 DOI: 10.1016/j.jtct.2021.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
Bortezomib-based triplet regimens-specifically bortezomib, lenalidomide, and dexamethasone (VRD) and bortezomib, cyclophosphamide, and dexamethasone (VCD)-are the 2 most common induction regimens used in transplantation-eligible patients with newly diagnosed multiple myeloma (NDMM), with conflicting data on comparative efficacy and outcomes in this population. We compared long-term outcomes of patients with NDMM receiving VRD induction and those receiving VCD induction prior to autologous stem cell transplantation (ASCT). Patients registered with the Center for International Blood and Marrow Transplant Registry were included if they had undergone ASCT for MM within 6 months of diagnosis between January 2013 and December 2018, received VRD or VCD induction, and achieved a pretransplantation partial or better response. Of 1135 patients, 914 received VRD and 221 received VCD. The patients receiving VCD were more likely to have renal impairment and International Staging System (ISS) stage III disease and less likely to receive full-dose melphalan (200 mg/m2) conditioning (69% versus 80%; P < .001). Very good partial response rates pretransplantation, post-transplantation, and at best response were not significantly different in the 2 groups. Maintenance use was more common after VRD induction (88% versus 76%; P < .001), with lenalidomide the most common agent (80% versus 63%). Patients in the VRD group had a higher rate of renal recovery (74% versus 43%; P < .001), possibly due to a rapid reduction of light chains in the VRD group or improvement in renal function with VCD, which allowed a switch over to VRD, as patients who switched were classified in the VRD group. Patients receiving VRD had better survival on univariate analysis, with a median progression-free survival (PFS) from transplantation of 44.6 months versus 34.1 months (P = .004) and median 5-year overall survival (OS) of 79% versus 60% (P < .001). Multivariate analysis showed no significant survival difference, with a hazard ratio for VCD versus VRD induction of 1.22 (95% CI, 0.96 to 1.55; P = .10) for PFS and 1.33 (95% CI, 0.93 to 1.92, P = .12) for OS. Maintenance use was independently associated with superior PFS and OS, along with ISS stage, cytogenetics, and pretransplantation response (PFS only). In patients with MM undergoing upfront ASCT after VRD or VCD induction, no independent survival difference was seen based on the induction therapy received after adjusting for other prognostic factors. The use of maintenance treatment was uniformly associated with superior outcomes. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
| | | | - Raphael Fraser
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vaibhav Agrawal
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Larry D. Anderson
- Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Rahul Banerjee
- Division of Hematology-Oncology; University of California San Francisco, San Francisco, CA
| | - Asad Bashey
- Blood and Marrow Transplant Program at the Northside Hospital, Atlanta, GA
| | | | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Rajshekhar Chakraborty
- Multiple Myeloma and Amyloidosis Service, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Binod Dhakal
- BMT and Cellular Therapy, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Shahrukh Hashmi
- 1. Department of Internal Medicine, Mayo Clinic, MN,Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Murali Janakiram
- University of Minnesota, Division of Hematology, Oncology, and Transplantation, Minneapolis, MN
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Hemant S. Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Ricardo Parrondo
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | | | - Saad Usmani
- Department of Hematologic Oncology & Blood Disorders Levine Cancer Institute/Atrium Health, Charlotte, NC
| | - Nina Shah
- Division of Hematology-Oncology; University of California San Francisco, San Francisco, CA
| | | | - Anita D’Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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161
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Peres LC, Hansen DK, Maura F, Kazandjian D. The knowns and unknowns of disparities, biology, and clinical outcomes in Hispanic and Latinx multiple myeloma patients in the U.S. Semin Oncol 2022; 49:3-10. [DOI: 10.1053/j.seminoncol.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/23/2022] [Indexed: 11/11/2022]
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Langerhans dendritic cell vaccines bearing mRNA-encoded tumor antigens induce anti-myeloma immunity after autotransplant. Blood Adv 2022; 6:1547-1558. [PMID: 35100339 PMCID: PMC8905697 DOI: 10.1182/bloodadvances.2021005941] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/03/2022] [Indexed: 11/20/2022] Open
Abstract
Triple antigen–bearing mRNA-electroporated autologous LC vaccines after ASCT for MM are safe and immunogenic.
Posttransplant vaccination targeting residual disease is an immunotherapeutic strategy to improve antigen-specific immune responses and prolong disease-free survival after autologous stem cell transplantation (ASCT) for multiple myeloma (MM). We conducted a phase 1 vaccine trial to determine the safety, toxicity, and immunogenicity of autologous Langerhans-type dendritic cells (LCs) electroporated with CT7, MAGE-A3, and Wilms tumor 1 (WT1) messenger RNA (mRNA), after ASCT for MM. Ten patients received a priming immunization plus 2 boosters at 12, 30, and 90 days, respectively, after ASCT. Vaccines contained 9 × 106 mRNA-electroporated LCs. Ten additional patients did not receive LC vaccines but otherwise underwent identical ASCT and supportive care. At 3 months after ASCT, all patients started lenalidomide maintenance therapy. Vaccinated patients developed mild local delayed-type hypersensitivity reactions after booster vaccines, but no toxicities exceeded grade 1. At 1 and 3 months after vaccines, antigen-specific CD4 and CD8 T cells increased secretion of proinflammatory cytokines (interferon-γ, interleukin-2, and tumor necrosis factor-α) above prevaccine levels, and also upregulated the cytotoxicity marker CD107a. CD4 and CD8 T-cell repertoire analysis showed a trend for increased clonal expansion in the vaccine cohort, which was more pronounced in the CD4 compartment. Although not powered to assess clinical efficacy, treatment responses favored the vaccine arm. Triple antigen–bearing mRNA-electroporated autologous LC vaccination initiated at engraftment after ASCT, in conjunction with standard lenalidomide maintenance therapy for MM, is safe and induces antigen-specific immune reactivity. This trial was registered at www.clinicaltrials.gov as #NCT01995708.
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163
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Kesireddy M, Holstein SA. The era of lenalidomide maintenance therapy in multiple myeloma: settings for achieving best outcomes. Expert Rev Clin Pharmacol 2022; 15:19-31. [DOI: 10.1080/17512433.2022.2032656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Meghana Kesireddy
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Sarah A. Holstein
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Abstract
Despite recent advances multiple myeloma remains an incurable disease for most of the patients and initial remission will be followed by relapses requiring therapy. For many, there will be several remissions and relapses until resistance develops to all available therapies. With the introduction of several new agents, myeloma treatment has changed drastically and there are new options for the management of relapsed or refractory disease, including new drug classes with distinct mechanisms of action and cellular therapies. However, resistance to major drug classes used in first line remain the most critical factor for the choice of treatment at relapse. Continuous lenalidomide-based therapy is used extensively at first line and resistance to lenalidomide has become the key factor for the choice of salvage therapy. Daratumumab is increasingly used in first line and soon patients that relapse while on daratumumab will become a common challenge. Three-drug regimens are standard approach to manage relapsed disease. Adding drugs with new mechanisms of activity can improves outcomes and overcomes class resistance but, until now, while the biology is important, can offer only limited guidance for the choice of therapy.
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165
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Hernández-Rivas JÁ, Ríos-Tamayo R, Encinas C, Alonso R, Lahuerta JJ. The changing landscape of relapsed and/or refractory multiple myeloma (MM): fundamentals and controversies. Biomark Res 2022; 10:1. [PMID: 35000618 PMCID: PMC8743063 DOI: 10.1186/s40364-021-00344-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/24/2021] [Indexed: 12/13/2022] Open
Abstract
The increase in the number of therapeutic alternatives for both newly diagnosed and relapsed/refractory multiple myeloma (RRMM) patients has widened the clinical scenario, leading to a level of complexity that no algorithm has been able to cover up to date. At present, this complexity increases due to the wide variety of clinical situations found in MM patients before they reach the status of relapsed/refractory disease. These different backgrounds may include primary refractoriness, early relapse after completion of first-line therapy with latest-generation agents, or very late relapse after chemotherapy or autologous transplantation. It is also important to bear in mind that many patient profiles are not fully represented in the main randomized clinical trials (RCT), and this further complicates treatment decision-making. In RRMM patients, the choice of previously unused drugs and the number and duration of previous therapeutic regimens until progression has a greater impact on treatment efficacy than the adverse biological characteristics of MM itself. In addition to proteasome inhibitors, immunomodulatory drugs, anti-CD38 antibodies and corticosteroids, a new generation of drugs such as XPO inhibitors, BCL-2 inhibitors, new alkylators and, above all, immunotherapy based on conjugated anti-BCMA antibodies and CAR-T cells, have been developed to fight RRMM. This comprehensive review addresses the fundamentals and controversies regarding RRMM, and discusses the main aspects of management and treatment. The basis for the clinical management of RRMM (complexity of clinical scenarios, key factors to consider before choosing an appropriate treatment, or when to treat), the arsenal of new drugs with no cross resistance with previously administered standard first line regimens (main phase 3 clinical trials), the future outlook including the usefulness of abandoned resources, together with the controversies surrounding the clinical management of RRMM patients will be reviewed in detail.
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Affiliation(s)
| | - Rafael Ríos-Tamayo
- Hospital Universitario Virgen de las Nieves, Instituto de Investigación Biosanitaria, Granada, Spain
| | - Cristina Encinas
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rafael Alonso
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan-José Lahuerta
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain.
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166
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DeStefano CB, Gibson SJ, Sperling AS, Richardson PG, Ghobrial I, Mo CC. The emerging importance and evolving understanding of clonal hematopoiesis in multiple myeloma. Semin Oncol 2022; 49:19-26. [DOI: 10.1053/j.seminoncol.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/09/2022] [Indexed: 12/19/2022]
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167
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Pasvolsky O, Yeshurun M, Fraser R, Estrada-Merly N, Rozovski U, Shargian L, Assal A, Banerjee R, Bumma N, Gale RP, Hagen P, Holmberg L, Hossain NM, Lazarus HM, Lee C, Mian H, Miller KC, Nathan S, Nagler A, Nishihori T, Parrondo RD, Patel S, Schroeder MA, Usmani SZ, Wang T, Wirk B, Kumar S, Shah N, Qazilbash MH, D’Souza A. Maintenance therapy after second autologous hematopoietic cell transplantation for multiple myeloma. A CIBMTR analysis. Bone Marrow Transplant 2022; 57:31-37. [PMID: 34608275 PMCID: PMC8764606 DOI: 10.1038/s41409-021-01455-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
The role of maintenance therapy after high-dose chemotherapy and first autologous transplantation in multiple myeloma (MM) is well established. We explored the effect of maintenance therapy on outcomes after salvage second autologous hematopoietic cell transplant (AHCT2) using the Center for International Blood and Marrow Transplant Research registry. Outcomes of interest included non-relapse mortality (NRM), relapse/progression (REL), progression-free and overall survival (PFS, OS). Of 522 patients who underwent AHCT2 between 2010 and 2018, 342 received maintenance therapy and 180 did not. Maintenance regimens included lenalidomide (42%), pomalidomide (13%), and bortezomib (13%). Median follow up was 58 months in the maintenance group and 61.5 months in the no-maintenance group. Univariate analysis showed superior outcomes at 5 years in maintenance compared to the no-maintenance group: NRM 2 (0.7-3.9)% vs 9.9 (5.9-14.9)%, (p < 0.01), REL 70.2 (64.4-75.8)% vs 80.3 (73.6-86.3)% (p < 0.01), PFS 27.8 (22.4-33.5)% vs. 9.8 (5.5-15.2)% (p < 0.01), and OS 54 (47.5-60.5)% vs 30.9 (23.2-39.2)% (p < 0.01), respectively. Use of maintenance therapy retained its association with improved outcomes in multivariate analysis. There was no difference in second cancers in the two groups (p = 0.39). We conclude that maintenance after AHCT2 is associated with improved 5-year outcomes.
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Affiliation(s)
- Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel;,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel;,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raphael Fraser
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI;,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel
| | - Amer Assal
- Columbia University Irving Medical Center, Department of Medicine, Bone Marrow Transplant and Cell Therapy Program, New York, NY
| | - Rahul Banerjee
- Division of Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | - Naresh Bumma
- Ohio State Medical Center, James Cancer Center, Columbus , OH
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
| | | | | | - Nasheed M. Hossain
- Department of Medicine, Division of Hematology/Oncology, Stem Cell Transplant Program – Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Hillard M. Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Hira Mian
- McMaster University, Hamilton, ON, Canada
| | | | - Sunita Nathan
- Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center, Chicago, IL
| | - Arnon Nagler
- Hematology Division and BMT, Chaim Sheba Medical Center, Tel Hashomer, Israel;,Tel Aviv University, Tel Aviv, Israel
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ricardo D Parrondo
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonsville, FL
| | - Sagar Patel
- Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mark A. Schroeder
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Saad Z. Usmani
- Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC
| | - Trent Wang
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA
| | | | - Nina Shah
- Division of Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | | | - Anita D’Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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168
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Chen H, Wang Y, Shao C, Sun C, Zheng C. Efficacy and safety of ixazomib maintenance therapy for patients with multiple myeloma: a meta-analysis. Hematology 2021; 26:1031-1039. [PMID: 34895096 DOI: 10.1080/16078454.2021.2009648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Multiple myeloma(MM) is a malignant plasma cell disease. Maintenance treatment is beneficial to prolong survival time in patients with MM. Ixazomib was approved for the treatment of relapsed or refractory MM in combination with lenalidomide and dexamethasone. Here, we carried out a meta-analysis to determine the efficacy and safety of ixazomib maintenance therapy. METHODS Several databases were searched including PubMed, Web of Science, Embase, the Cochrane Library, etc. The last search dated back to July, 2020. Three clinical trials with a total of 1440 participants with newly diagnosed MM were included. RESULTS AND CONCLUSION The pooled HR of progression-free survival (PFS) was 0.69 (95% CI = 0.59-0.79), which suggested ixazomib maintenance therapy could prolong PFS remarkably. In addition, ixazomib was effective in deepening remission (RR = 1.57, 95% CI = 1.26-1.96). But it could not significantly prolong PFS in cytogenetic high-risk patients (HR = 0.74, 95% CI = 0.47-1.00). In terms of adverse reactions, our analysis revealed higher incidences of grade 3-4 thrombocytopenia (RR = 7.47, 95% CI = 2.06-27.06), neuropathy (RR = 1.48, 95% CI = 1.14-1.92), grade 3-4 infections (RR = 1.77, 95% CI = 1.21-2.59) and gastrointestinal disorders (RR = 1.48, 95% CI = 1.32-1.66). There was no significant correlation between the use of ixazomib and grade 3-4 neutropenia (RR = 1.46, 95% CI = 0.77-2.78, p = 0.25) or the occurrence of new primary malignant tumor (RR = 0.88, 95% CI = 0.53-1.46, p = 0.62). Additionally, more RCTs are needed for better choice of treatment regimen.
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Affiliation(s)
- Huixian Chen
- Department of Hematology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Yongjing Wang
- Department of Hematology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China.,Shandong University-Karolinska Institute Collaboration Laboratory for Stem Cell Research, Jinan, People's Republic of China.,Institute of Biotherapy for Hematological Malignancies, Shandong University, Jinan, People's Republic of China
| | - Chunchun Shao
- Center of Evidence-Based Medicine, Institute of Medical Sciences, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Chenxi Sun
- Department of Hematology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Chengyun Zheng
- Department of Hematology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China.,Shandong University-Karolinska Institute Collaboration Laboratory for Stem Cell Research, Jinan, People's Republic of China.,Institute of Biotherapy for Hematological Malignancies, Shandong University, Jinan, People's Republic of China
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169
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Oganesyan A, Ghahramanyan N, Mekinian A, Bejanyan N, Kazandjian D, Hakobyan Y. Managing multiple myeloma in a resource-limited region: Diagnosis and treatment in Armenia. Semin Oncol 2021; 48:269-278. [PMID: 34895914 DOI: 10.1053/j.seminoncol.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 11/11/2022]
Abstract
Multiple myeloma (MM) is the second most common blood cancer in adults leading to 117,000 deaths every year. Major breakthroughs in clinical research of the past decades transformed the diagnosis and treatment of MM improving the survival rates and overall quality of life of patients. Unfortunately, scientific advancements are not distributed equally around the globe leading to disparities in the treatment outcomes between different regions of the world. Management of MM in low- and middle-income countries represents a big challenge for healthcare providers considering the economic, technological, and infrastructural restraints in comparison to developed countries. Many standards of practice, including diagnostic tools and therapeutic regimens, are not available in developing regions of the world. As an example of an upper-middle-income country, Armenia has been witnessing considerable progress in the diagnosis and treatment of MM, including but not limited to the establishment of autologous stem cell transplant (ASCT), accessibility to modern anti-myeloma medications, and improved diagnostic and monitoring workup. Despite significant improvements, there is still a need for refinement in the management of MM. The aim of this review article is to discuss the latest developments and the current diagnosis and treatment of MM in Armenia as an example of a resource-limited region.
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Affiliation(s)
- Artem Oganesyan
- Myeloma Research Group, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Nerses Ghahramanyan
- Myeloma Research Group, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Arsene Mekinian
- French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia; AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Sorbonne Université, Paris, France
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Yervand Hakobyan
- Myeloma Research Group, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia; French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia.
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170
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Costa LJ, Chhabra S, Medvedova E, Dholaria BR, Schmidt TM, Godby KN, Silbermann R, Dhakal B, Bal S, Giri S, D'Souza A, Hall A, Hardwick P, Omel J, Cornell RF, Hari P, Callander NS. Daratumumab, Carfilzomib, Lenalidomide, and Dexamethasone With Minimal Residual Disease Response-Adapted Therapy in Newly Diagnosed Multiple Myeloma. J Clin Oncol 2021; 40:2901-2912. [PMID: 34898239 DOI: 10.1200/jco.21.01935] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The MASTER trial combined daratumumab, carfilzomib, lenalidomide, and dexamethasone (Dara-KRd) in newly diagnosed multiple myeloma (NDMM), using minimal residual disease (MRD) by next-generation sequencing (NGS) to inform the use and duration of Dara-KRd post-autologous hematopoietic cell transplantation (AHCT) and treatment cessation in patients with two consecutive MRD-negative assessments. METHODS This multicenter, single-arm, phase II trial enrolled patients with NDMM with planed enrichment for high-risk cytogenetic abnormalities (HRCAs). Patients received Dara-KRd induction, AHCT, and Dara-KRd consolidation, according to MRD status. MRD was evaluated by NGS at the end of induction, post-AHCT, and every four cycles (maximum of eight cycles) of consolidation. Primary end point was achievement of MRD negativity (< 10-5). Patients with two consecutive MRD-negative assessments entered treatment-free MRD surveillance. RESULTS Among 123 participants, 43% had none, 37% had 1, and 20% had 2+ HRCA. Median age was 60 years (range, 36-79 years), and 96% had MRD trackable by NGS. Median follow-up was 25.1 months. Overall, 80% of patients reached MRD negativity (78%, 82%, and 79% for patients with 0, 1, and 2+ HRCA, respectively), 66% reached MRD < 10-6, and 71% reached two consecutive MRD-negative assessments during therapy, entering treatment-free surveillance. Two-year progression-free survival was 87% (91%, 97%, and 58% for patients with 0, 1, and 2+ HRCA, respectively). Cumulative incidence of MRD resurgence or progression 12 months after cessation of therapy was 4%, 0%, and 27% for patients with 0, 1, or 2+ HRCA, respectively. Most common serious adverse events were pneumonia (6%) and venous thromboembolism (3%). CONCLUSION Dara-KRd, AHCT, and MRD response-adapted consolidation leads to high rate of MRD negativity in NDMM. For patients with 0 or 1 HRCA, this strategy creates the opportunity of MRD surveillance as an alternative to indefinite maintenance.
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Affiliation(s)
- Luciano J Costa
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL.,O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham, Birmingham, AL
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Bhagirathbhai R Dholaria
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Kelly N Godby
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL.,O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham, Birmingham, AL
| | | | - Binod Dhakal
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Bal
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL.,O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham, Birmingham, AL
| | - Smith Giri
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL.,O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham, Birmingham, AL
| | - Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Aric Hall
- University of Wisconsin, Madison, WI
| | - Pamela Hardwick
- O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham, Birmingham, AL
| | | | - Robert F Cornell
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Parameswaran Hari
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Virdis P, Migheli R, Bordoni V, Fiorentino FP, Sanna L, Marchesi I, Pintore G, Galleri G, Muroni MR, Bagella L, Fozza C, De Miglio MR, Podda L. Clarifying the molecular mechanism of tomentosin‑induced antiproliferative and proapoptotic effects in human multiple myeloma via gene expression profile and genetic interaction network analysis. Int J Mol Med 2021; 48:213. [PMID: 34643251 PMCID: PMC8522960 DOI: 10.3892/ijmm.2021.5046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022] Open
Abstract
Multiple myeloma (MM) is an aggressive B cell malignancy. Substantial progress has been made in the therapeutic context for patients with MM, however it still represents an incurable disease due to drug resistance and recurrence. Development of more effective or synergistic therapeutic approaches undoubtedly represents an unmet clinical need. Tomentosin is a bioactive natural sesquiterpene lactone extracted by various plants with therapeutic properties, including anti‑neoplastic effects. In the present study, the potential antitumor activity of tomentosin was evaluated on the human RPMI‑8226 cell line, treated with increasing tomentosin concentration for cytotoxicity screening. The data suggested that both cell cycle arrest and cell apoptosis could explain the antiproliferative effects of tomentosin and may result in the inhibition of RPMI‑8226 cell viability. To assess differentially expressed genes contributing to tomentosin activity and identify its mechanism of action, a microarray gene expression profile was performed, identifying 126 genes deregulated by tomentosin. To address the systems biology and identify how tomentosin deregulates gene expression in MM from a systems perspective, all deregulated genes were submitted to enrichment and molecular network analysis. The Protein‑Protein Interaction (PPI) network analysis showed that tomentosin in human MM induced the downregulation of genes involved in several pathways known to lead immune‑system processes, such as cytokine‑cytokine receptor interaction, chemokine or NF‑κB signaling pathway, as well as genes involved in pathways playing a central role in cellular neoplastic processes, such as growth, proliferation, migration, invasion and apoptosis. Tomentosin also induced endoplasmic reticulum stress via upregulation of cyclic AMP‑dependent transcription factor ATF‑4 and DNA damage‑inducible transcript 3 protein genes, suggesting that in the presence of tomentosin the protective unfolded protein response signaling may induce cell apoptosis. The functional connections analysis executed using the Connectivity Map tool, suggested that the effects of tomentosin on RPMI‑8226 cells might be similar to those exerted by heat shock proteins inhibitors. Taken together, these data suggested that tomentosin may be a potential drug candidate for the treatment of MM.
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Affiliation(s)
- Patrizia Virdis
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Rossana Migheli
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Valentina Bordoni
- Department of Biomedical Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | | | - Luca Sanna
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Irene Marchesi
- Kitos Biotech Srls, Porto Conte Ricerche, I-07100 Sassari, Sardinia, Italy
| | - Giorgio Pintore
- Department of Chemistry and Pharmacy, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Grazia Galleri
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Maria Rosaria Muroni
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Luigi Bagella
- Department of Biomedical Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA
| | - Claudio Fozza
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Maria Rosaria De Miglio
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
| | - Luigi Podda
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, I-07100 Sassari, Sardinia, Italy
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Aksenova AY, Zhuk AS, Lada AG, Zotova IV, Stepchenkova EI, Kostroma II, Gritsaev SV, Pavlov YI. Genome Instability in Multiple Myeloma: Facts and Factors. Cancers (Basel) 2021; 13:5949. [PMID: 34885058 PMCID: PMC8656811 DOI: 10.3390/cancers13235949] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/20/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
Multiple myeloma (MM) is a malignant neoplasm of terminally differentiated immunoglobulin-producing B lymphocytes called plasma cells. MM is the second most common hematologic malignancy, and it poses a heavy economic and social burden because it remains incurable and confers a profound disability to patients. Despite current progress in MM treatment, the disease invariably recurs, even after the transplantation of autologous hematopoietic stem cells (ASCT). Biological processes leading to a pathological myeloma clone and the mechanisms of further evolution of the disease are far from complete understanding. Genetically, MM is a complex disease that demonstrates a high level of heterogeneity. Myeloma genomes carry numerous genetic changes, including structural genome variations and chromosomal gains and losses, and these changes occur in combinations with point mutations affecting various cellular pathways, including genome maintenance. MM genome instability in its extreme is manifested in mutation kataegis and complex genomic rearrangements: chromothripsis, templated insertions, and chromoplexy. Chemotherapeutic agents used to treat MM add another level of complexity because many of them exacerbate genome instability. Genome abnormalities are driver events and deciphering their mechanisms will help understand the causes of MM and play a pivotal role in developing new therapies.
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Affiliation(s)
- Anna Y. Aksenova
- Laboratory of Amyloid Biology, St. Petersburg State University, 199034 St. Petersburg, Russia
| | - Anna S. Zhuk
- International Laboratory “Computer Technologies”, ITMO University, 197101 St. Petersburg, Russia;
| | - Artem G. Lada
- Department of Microbiology and Molecular Genetics, University of California, Davis, CA 95616, USA;
| | - Irina V. Zotova
- Department of Genetics and Biotechnology, St. Petersburg State University, 199034 St. Petersburg, Russia; (I.V.Z.); (E.I.S.)
- Vavilov Institute of General Genetics, St. Petersburg Branch, Russian Academy of Sciences, 199034 St. Petersburg, Russia
| | - Elena I. Stepchenkova
- Department of Genetics and Biotechnology, St. Petersburg State University, 199034 St. Petersburg, Russia; (I.V.Z.); (E.I.S.)
- Vavilov Institute of General Genetics, St. Petersburg Branch, Russian Academy of Sciences, 199034 St. Petersburg, Russia
| | - Ivan I. Kostroma
- Russian Research Institute of Hematology and Transfusiology, 191024 St. Petersburg, Russia; (I.I.K.); (S.V.G.)
| | - Sergey V. Gritsaev
- Russian Research Institute of Hematology and Transfusiology, 191024 St. Petersburg, Russia; (I.I.K.); (S.V.G.)
| | - Youri I. Pavlov
- Eppley Institute for Research in Cancer, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Departments of Biochemistry and Molecular Biology, Microbiology and Pathology, Genetics Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198, USA
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173
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Jeryczynski G, Bolomsky A, Agis H, Krauth MT. Stratification for RRMM and Risk-Adapted Therapy: Sequencing of Therapies in RRMM. Cancers (Basel) 2021; 13:5886. [PMID: 34885001 PMCID: PMC8657274 DOI: 10.3390/cancers13235886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022] Open
Abstract
The treatment landscape for relapsed multiple myeloma (RRMM) has experienced an unprecedented wave of innovation. Implementation of numerous new substances and drug classes with different modes of action is made possible in routine clinical practice. Next generation proteasome inhibitors, monoclonal antibodies, as well as first in class agents such as selinexor and venetoclax have widened the therapeutic spectrum. This has led to an increase in progression-free and overall survival. Consequently, new challenges for treating physicians in choosing the right treatment at the right stage of the disease have been generated. Several trials support the use of novel agents in the frontline treatment of newly diagnosed multiple myeloma. The use of lenalidomide or bortezomib as a backbone in the first-line setting, requires strategies for treatment once these patients relapse and are refractory to these drugs. Despite the variety of options, selecting the optimal treatment strategy is difficult, since multiple factors have to be considered: patient-specific factors such as age and co-morbidities, as well as myeloma/tumor specific factors such as cytogenetics and relapse kinetics. This review intends to summarize the existing data and guidelines regarding the optimal sequencing of treatments of RRMM using already approved agents as well as agents under investigation.
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Affiliation(s)
- Georg Jeryczynski
- Division of Oncology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria;
| | - Arnold Bolomsky
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Hermine Agis
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, 1080 Vienna, Austria;
| | - Maria-Theresa Krauth
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, 1080 Vienna, Austria;
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174
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How I Treat Frontline Transplant-eligible Multiple Myeloma. Blood 2021; 139:2882-2888. [PMID: 34788422 DOI: 10.1182/blood.2020008735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 11/05/2021] [Indexed: 11/20/2022] Open
Abstract
High dose Melphalan supported by autologous transplantation is the standard of care for eligible patients with newly diagnosed multiple myeloma for more than 25 years. Several randomized clinical trials have recently reaffirmed the strong position of transplant in the era of proteasome inhibitors and immunomodulatory drugs combinations, demonstrating a significant reduction of progression or death in comparison with strategies without transplant. Immunotherapy is currently changing the paradigm of multiple myeloma management and daratumumab is the first-in-class human monoclonal antibody targeting CD38 approved in the setting of newly diagnosed multiple myeloma. Quadruplets become the new standard in the transplantation programs, but outcomes remain heterogeneous with various response depth and duration. Otherwise, the development of sensitive and specific tools for disease prognostication allows to consider adaptive strategy to a dynamic risk. I discuss in this review the different available options for the treatment of transplant-eligible multiple myeloma patients in frontline setting.
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Carfilzomib with cyclophosphamide and dexamethasone or lenalidomide and dexamethasone plus autologous transplantation or carfilzomib plus lenalidomide and dexamethasone, followed by maintenance with carfilzomib plus lenalidomide or lenalidomide alone for patients with newly diagnosed multiple myeloma (FORTE): a randomised, open-label, phase 2 trial. Lancet Oncol 2021; 22:1705-1720. [PMID: 34774221 DOI: 10.1016/s1470-2045(21)00535-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bortezomib-based induction followed by high-dose melphalan (200 mg/m2) and autologous stem-cell transplantation (MEL200-ASCT) and maintenance treatment with lenalidomide alone is the current standard of care for young and fit patients with newly diagnosed multiple myeloma. We aimed to evaluate the efficacy and safety of different carfilzomib-based induction and consolidation approaches with or without transplantation and of maintenance treatment with carfilzomib plus lenalidomide versus lenalidomide alone in newly diagnosed multiple myeloma. METHODS UNITO-MM-01/FORTE was a randomised, open-label, phase 2 trial done in 42 Italian academic and community practice centres. We enrolled transplant-eligible patients with newly diagnosed multiple myeloma aged 65 years or younger with a Karnofsky Performance Status of 60% or higher. Patients were stratified according to International Staging System stage (I vs II/III) and age (<60 years vs 60-65 years) and randomly assigned (1:1:1) to KRd plus ASCT (four 28-day induction cycles with carfilzomib plus lenalidomide plus dexamethasone [KRd], melphalan at 200 mg/m2 and autologous stem-cell transplantation [MEL200-ASCT], followed by four 28-day KRd consolidation cycles), KRd12 (12 28-day KRd cycles), or KCd plus ASCT (four 28-day induction cycles with carfilzomib plus cyclophosphamide plus dexamethasone [KCd], MEL200-ASCT, and four 28-day KCd consolidation cycles). Carfilzomib 36 mg/m2 was administered intravenously on days 1, 2, 8, 9, 15, and 16; lenalidomide 25 mg administered orally on days 1-21; cyclophosphamide 300 mg/m2 administered orally on days 1, 8, and 15; and dexamethasone 20 mg administered orally or intravenously on days 1, 2, 8, 9, 15, 16, 22, and 23. Thereafter, patients were stratified according to induction-consolidation treatment and randomly assigned (1:1) to maintenance treatment with carfilzomib plus lenalidomide or lenalidomide alone. Carfilzomib 36 mg/m2 was administered intravenously on days 1-2 and 15-16 every 28 days for up to 2 years; lenalidomide 10 mg was administered orally on days 1-21 every 28 days until progression or intolerance in both groups. The primary endpoints were the proportion of patients with at least a very good partial response after induction with KRd versus KCd and progression-free survival with carfilzomib plus lenalidomide versus lenalidomide alone as maintenance treatment, both assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02203643. Study recruitment is complete, and all patients are in the follow-up or maintenance phases. FINDINGS Between Feb 23, 2015, and April 5, 2017, 474 patients were randomly assigned to one of the induction-intensification-consolidation groups (158 to KRd plus ASCT, 157 to KRd12, and 159 to KCd plus ASCT). The median duration of follow-up was 50·9 months (IQR 45·7-55·3) from the first randomisation. 222 (70%) of 315 patients in the KRd group and 84 (53%) of 159 patients in the KCd group had at least a very good partial response after induction (OR 2·14, 95% CI 1·44-3·19, p=0·0002). 356 patients were randomly assigned to maintenance treatment with carfilzomib plus lenalidomide (n=178) or lenalidomide alone (n=178). The median duration of follow-up was 37·3 months (IQR 32·9-41·9) from the second randomisation. 3-year progression-free survival was 75% (95% CI 68-82) with carfilzomib plus lenalidomide versus 65% (58-72) with lenalidomide alone (hazard ratio [HR] 0·64 [95% CI 0·44-0·94], p=0·023). During induction and consolidation, the most common grade 3-4 adverse events were neutropenia (21 [13%] of 158 patients in the KRd plus ASCT group vs 15 [10%] of 156 in the KRd12 group vs 18 [11%] of 159 in the KCd plus ASCT group); dermatological toxicity (nine [6%] vs 12 [8%] vs one [1%]); and hepatic toxicity (13 [8%] vs 12 [8%] vs none). Treatment-related serious adverse events were reported in 18 (11%) of 158 patients in the KRd-ASCT group, 29 (19%) of 156 in the KRd12 group, and 17 (11%) of 159 in the KCd plus ASCT group; the most common serious adverse event was pneumonia, in seven (4%) of 158, four (3%) of 156, and five (3%) of 159 patients. Treatment-emergent deaths were reported in two (1%) of 158 patients in the KRd plus ASCT group, two (1%) of 156 in the KRd12 group, and three (2%) of 159 in the KCd plus ASCT group. During maintenance, the most common grade 3-4 adverse events were neutropenia (35 [20%] of 173 patients on carfilzomib plus lenalidomide vs 41 [23%] of 177 patients on lenalidomide alone); infections (eight [5%] vs 13 [7%]); and vascular events (12 [7%] vs one [1%]). Treatment-related serious adverse events were reported in 24 (14%) of 173 patients on carfilzomib plus lenalidomide versus 15 (8%) of 177 on lenalidomide alone; the most common serious adverse event was pneumonia, in six (3%) of 173 versus five (3%) of 177 patients. One patient died of a treatment-emergent adverse event in the carfilzomib plus lenalidomide group. INTERPRETATION Our data show that KRd plus ASCT showed superiority in terms of improved responses compared with the other two treatment approaches and support the prospective randomised evaluation of KRd plus ASCT versus standards of care (eg, daratumumab plus bortezomib plus thalidomide plus dexamethasone plus ASCT) in transplant-eligible patients with multiple myeloma. Carfilzomib plus lenalidomide as maintenance therapy also improved progression-free survival compared with the standard-of-care lenalidomide alone. FUNDING Amgen, Celgene/Bristol Myers Squibb. TRANSLATION For the Italian translation of the abstract see Supplementary Materials section.
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Daratumumab in newly diagnosed MM - incorporating lessons learnt from CASSIOPEIA, MAIA and beyond. Nat Rev Clin Oncol 2021; 19:3-4. [PMID: 34773086 DOI: 10.1038/s41571-021-00581-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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177
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MCT1 is a Predictive Marker for Lenalidomide Maintenance Therapy in Multiple Myeloma. Blood Adv 2021; 6:515-520. [PMID: 34768284 PMCID: PMC8791591 DOI: 10.1182/bloodadvances.2021005532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/22/2021] [Indexed: 11/20/2022] Open
Abstract
High gene expression levels of MCT1 are associated with reduced PFS and OS in MM with lenalidomide-based maintenance therapy. Overexpression of MCT1 impairs efficacy of lenalidomide in human myeloma cells in vitro and in vivo.
Biomarkers that predict response to lenalidomide maintenance therapy in patients with multiple myeloma (MM) have remained elusive. We have shown that immunomodulatory drugs (IMiDs) exert anti-MM activity via destabilization of MCT1 and CD147. In this study, cell samples of 654 patients with MM who received lenalidomide (n = 455), thalidomide (n = 98), or bortezomib (n = 101) maintenance were assessed by gene expression profiling and RNA sequencing, followed by correlation of MCT1 and CD147 expression with data for progression-free survival (PFS) and overall survival (OS). Patients with high expression levels of MCT1 showed significantly reduced PFS (31.9 months vs 48.2 months in MCT1high vs MCT1low; P = .03) and OS (75.9 months vs not reached [NR] in MCT1high vs MCT1low; P = .001) in cases with lenalidomide maintenance, whereas MCT1 expression had no significant impact on PFS or OS in cases with bortezomib maintenance. We validated the predictive role of MCT1 for IMiD-based maintenance in an independent cohort of patients who received thalidomide (OS, 83.6 months vs NR in MCT1high vs MCT1low; P = .03). Functional validation showed that MCT1 overexpression in human MM cell lines significantly reduced the efficacy of lenalidomide, whereas no change was observed with bortezomib treatment, either in vitro or in a MM xenograft model. Our findings have established MCT1 expression as a predictive marker for response to lenalidomide-based maintenance in patients with MM.
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Sonneveld P, Dimopoulos MA, Beksac M, van der Holt B, Aquino S, Ludwig H, Zweegman S, Zander T, Zamagni E, Wester R, Hajek R, Pantani L, Dozza L, Gay F, Cafro A, De Rosa L, Morelli A, Gregersen H, Gulbrandsen N, Cornelisse P, Troia R, Oliva S, van de Velden V, Wu K, Ypma PF, Bos G, Levin MD, Pour L, Driessen C, Broijl A, Croockewit A, Minnema MC, Waage A, Hveding C, van de Donk NWCJ, Offidani M, Palumbo GA, Spencer A, Boccadoro M, Cavo M. Consolidation and Maintenance in Newly Diagnosed Multiple Myeloma. J Clin Oncol 2021; 39:3613-3622. [PMID: 34520219 DOI: 10.1200/jco.21.01045] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To address the role of consolidation treatment for newly diagnosed, transplant eligible patients with multiple myeloma in a controlled clinical trial. PATIENTS AND METHODS The EMN02/HOVON95 trial compared consolidation treatment with two cycles of bortezomib, lenalidomide, and dexamethasone (VRD) or no consolidation after induction and intensification therapy, followed by continuous lenalidomide maintenance. Primary study end point was progression-free survival (PFS). RESULTS Eight hundred seventy-eight eligible patients were randomly assigned to receive VRD consolidation (451 patients) or no consolidation (427 patients). At a median follow-up of 74.8 months, median PFS with adjustment for pretreatment was prolonged in patients randomly assigned to VRD consolidation (59.3 v 42.9 months, hazard ratio [HR] = 0.81; 95% CI, 0.68 to 0.96; P = .016). The PFS benefit was observed across most predefined subgroups, including revised International Staging System (ISS) stage, cytogenetics, and prior treatment. Revised ISS3 stage (HR, 2.00; 95% CI, 1.41 to 2.86) and ampl1q (HR, 1.67; 95% CI, 1.37 to 2.04) were significant adverse prognostic factors. The median duration of maintenance was 33 months (interquartile range 13-86 months). Response ≥ complete response (CR) after consolidation versus no consolidation before start of maintenance was 34% versus 18%, respectively (P < .001). Response ≥ CR on protocol including maintenance was 59% with consolidation and 46% without (P < .001). Minimal residual disease analysis by flow cytometry in a subgroup of 226 patients with CR or stringent complete response or very good partial response before start of maintenance demonstrated a 74% minimal residual disease-negativity rate in VRD-treated patients. Toxicity from VRD was acceptable and manageable. CONCLUSION Consolidation treatment with VRD followed by lenalidomide maintenance improves PFS and depth of response in newly diagnosed patients with multiple myeloma as compared to maintenance alone.
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Affiliation(s)
- Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Bronno van der Holt
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sara Aquino
- IRCCS Azienda Ospedaliera Universitaria San Martino, IST Instituto Nazionale per la Ricerca sul Cancro, Genova, Italy
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, c/o Wilhelminenspital, Vienna, Austria
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Thilo Zander
- Medical Oncology, Luzerner Kantonshospital, Luzern, Switzerland
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli" and Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Ruth Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Roman Hajek
- University Hospital Ostrava, Ostrava, Czech Republic
| | - Lucia Pantani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy
| | - Luca Dozza
- Department of Experimental, Diagnostic and Experimental Medicine, Seràgnoli Institute of Hematology, Bologna University School of Medicine, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | | | | | - Annamaria Morelli
- Department of Hematology, Transfusion Medicine and Biotechnology Santo Spirito, Civic Hospital, Pescara, Italy
| | - Henrik Gregersen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Nina Gulbrandsen
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Petra Cornelisse
- HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Rosella Troia
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | | | - KaLung Wu
- Department of Hematology, ZNA Stuivenberg, Antwerp, Belgium
| | - Paula F Ypma
- Department of Hematology, Haga Ziekenhuis, The Hague, the Netherlands
| | - Gerard Bos
- Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Luca Pour
- University Hospital Brno, Brno, Czech Republic
| | - Christoph Driessen
- Department of Oncology/Hematology, Kantonsspital, St Gallen, Switzerland
| | - Annemiek Broijl
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alexandra Croockewit
- Department of Hematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Monique C Minnema
- Department of Hematology, University Medical Centre Utrecht, the Netherlands
| | - Anders Waage
- Department of Hematology, St Olav Hospital, Trondheim, Norway
| | | | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Massimo Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Giuseppe A Palumbo
- Department of Scienze Mediche Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia," University of Catania, Catania, Italy
| | - Andrew Spencer
- Department of Haematology, Alfred Hospital-Monash University, Melbourne, Australia
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Michele Cavo
- IRCCS S.Orsola-Malpighi, Istituto di Ematologia "Seràgnoli," Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi di Bologna, Bologna, Italy
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Heider M, Nickel K, Högner M, Bassermann F. Multiple Myeloma: Molecular Pathogenesis and Disease Evolution. Oncol Res Treat 2021; 44:672-681. [PMID: 34749378 DOI: 10.1159/000520312] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple myeloma is the second most common hematologic malignancy, which to date remains incurable despite advances in treatment strategies including the use of novel substances such as proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. SUMMARY The bone marrow-based disease is preceded by the 2 sequential premalignant conditions: monoclonal gammo-pathy of undetermined significance and smoldering myeloma. Plasma cell leukemia and extramedullary disease occur, when malignant clones lose their dependency on the bone marrow. Key genetic features of these plasma cell dyscrasias include chromosomal aberrations such as translocations and hyperdiploidy, which occur during error-prone physiologic processes in B-cell development. Next-generation sequencing studies have identified mutations in major oncogenic pathways and tumor suppressors, which contribute to the pathogenesis of multiple myeloma and have revealed insights into the clonal evolution of the disease, particularly along different lines of therapy. More recently, the importance of epigenetic alterations and the role of the bone marrow microenvironment, including immune and osteogenic cells, have become evident. Key Messages: We herein review the current knowledge of the pathogenesis of multiple myeloma, which is crucial for the development of novel targeted therapeutic strategies. These can contribute to the endeavor to make multiple myeloma a curable disease.
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Affiliation(s)
- Michael Heider
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,TranslaTUM, Center for Translational Cancer Research, Technical University of Munich, Munich, Germany
| | - Katharina Nickel
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marion Högner
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Bassermann
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,TranslaTUM, Center for Translational Cancer Research, Technical University of Munich, Munich, Germany
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180
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How I Treat High-risk Multiple Myeloma. Blood 2021; 139:2889-2903. [PMID: 34727187 DOI: 10.1182/blood.2020008733] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/26/2021] [Indexed: 11/20/2022] Open
Abstract
Survival of multiple myeloma (MM) has significantly improved over the last decade; however, a composed group of patients (15-20%), named high-risk (HR) MM, still experience reduced survival. Both tumor biology and suboptimal/absent responses to therapy may underlie HR definition and a clear uniform identification of risk factors is crucial for a proper management of these patients. In biologic-HRMM, MRD negativity attainment and sustain, inside and outside BM, should be the primary goal and therapy should be adapted in patients with frailty to reduce toxicity and improve quality of life. MM treatment has traditionally been tailored on age and more recently frailty or comorbidities, but very rarely on the biology of the disease, mainly because of the lack of a clear benefit derived from a specific drug/combination, inhomogeneity in HR definition and lack of data coming from prospective, properly designed clinical trials. Some attempts have been successfully made recently in this direction. In this review, we are discussing the current different definitions of HR and the need for a consensus, the results of available trials in HR patients and the way through risk-adapted treatment strategies. For this purpose, we are proposing several clinical cases of difficult-to-treat patients throughout different treatment phases.
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181
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Nakaya A, Shibayama H, Nakatani E, Shimura Y, Kosugi S, Tanaka H, Fuchida S, Kanda J, Uoshima N, Kaneko H, Imada K, Ohta K, Ito T, Yagi H, Yoshihara S, Hino M, Shimazaki C, Takaori‐Kondo A, Kuroda J, Matsumura I, Kanakura Y, Nomura S. Significance of maintenance therapy after HDT/ASCT in symptomatic multiple myeloma: A multicenter retrospective analysis in Kansai Myeloma Forum. EJHAEM 2021; 2:765-773. [PMID: 35845216 PMCID: PMC9175982 DOI: 10.1002/jha2.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 06/15/2023]
Abstract
A total of 129 symptomatic patients with multiple myeloma (MM) who underwent high-dose chemotherapy with autologous stem cell transplantation (HDT/ASCT) were analyzed. The 4-year overall survival (OS) of patients with maintenance (n = 82) was 80%, whereas that of patients without maintenance (n = 47) was 72% (p = 0.426). The 4-year progression-free survival (PFS) of patients with maintenance was 38%, whereas that of patients without maintenance was 27% (p = 0.088). Multivariate analysis revealed that an International Staging System score ≥2 was associated with worse PFS (hazard ratio 1.62, p = 0.043). Among the 129 patients, two were excluded owing to early relapse, 50 patients achieved complete response (CR), and 77 patients failed to achieve CR. Patients who achieved CR showed better 4-year PFS than those who failed to achieve CR (41% vs. 30%, p = 0.027); however, 4-year OS was not different (76% vs. 82%, p = 0.971). In patients who achieved CR, 4-year OS with/without maintenance was 74%/81% (p = 0.357), 4-year PFS with/without maintenance was 42%/40% (p = 0.954). In patients who failed to achieve CR, the 4-year OS with/without maintenance was 97%/91% (p = 0.107), and 4-year PFS with/without maintenance was 36%/16% (p < 0.001). In patients who failed to achieve CR, maintenance significantly improved the PFS. Maintenance after HDT/ASCT can prolong PFS in patients who fail to achieve CR in real-world settings.
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182
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Kumar SK. Newly Diagnosed Multiple Myeloma: How Many Drugs Are Enough? J Natl Compr Canc Netw 2021. [DOI: 10.6004/jnccn.2021.5104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The treatment of multiple myeloma (MM) has evolved over the past decade, yet it remains a chronic disease. Several trials of 4-drug induction regimens have resulted in deepening of disease response. With the emergence of multidrug regimens, questions have arisen regarding the role of autologous stem cell transplant (ASCT) in MM therapy and available treatment options after ASCT. Clinicians have also continued to improve the efficacy of maintenance therapies. In transplant-ineligible patients, the phases of treatment are less distinct; however, several regimens have demonstrated efficacy in this clinical setting. Future research should focus on individualizing treatment approaches.
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183
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Gaballa MR, Ma J, Tanner MR, Al-Juhaishi T, Bashir Q, Srour SA, Saini NY, Ramdial JL, Nieto Y, Murphy R, Rezvani K, Tang G, Lee HC, Patel KK, Kaufman GP, Manasanch EE, Ullah MR, Kebriaei P, Thomas SK, Weber DM, Orlowski RZ, Shpall EJ, Champlin RE, Qazilbash MH. Real-world long-term outcomes in multiple myeloma with VRD induction, Mel200-conditioned auto-HCT, and lenalidomide maintenance. Leuk Lymphoma 2021; 63:710-721. [PMID: 34686083 DOI: 10.1080/10428194.2021.1992763] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Standard-of-care for newly-diagnosed, autologous hematopoietic stem cell transplantation (auto-HCT)-eligible, multiple myeloma (MM) patients includes bortezomib, lenalidomide, and dexamethasone (VRD) induction followed by melphalan 200 mg/m2 (Mel200)-conditioned auto-HCT and lenalidomide maintenance. We completed a retrospective case series assessing outcomes of 187 MM patients who received this regimen at our institution. The 100-day non-relapse mortality incidence was zero. Before auto-HCT, 9.6 and 52.9% of patients achieved a complete response (CR) or ≥ very good partial response (VGPR), respectively. At day-100 post-transplant, 29.4 and 74.9% had achieved a CR/stringent-CR (sCR) or ≥ VGPR, respectively. At the last evaluation, 57.2% of patients had CR/sCR and 87.1% had ≥ VGPR. Median follow-up, progression-free survival (PFS), and overall survival (OS) were 63.2, 50, and 101.7 months, respectively. The 5-year PFS and OS were 43.1 and 79%. High-risk cytogenetics was associated with worse outcomes. This study illustrates that VRD induction, Mel200-conditioned auto-HCT, and lenalidomide maintenance are associated with good outcomes in MM.
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Affiliation(s)
- Mahmoud R Gaballa
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA.,Bone Marrow Transplant and Cellular Immunotherapy Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Junsheng Ma
- Department of Biostatistics, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Mark R Tanner
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Taha Al-Juhaishi
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Qaiser Bashir
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Samer A Srour
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Neeraj Y Saini
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Jeremy L Ramdial
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Yago Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Regan Murphy
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Guilin Tang
- Division of Pathology and Laboratory Medicine, Department of Hematopathology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Hans C Lee
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Krina K Patel
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Gregory P Kaufman
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Elisabet E Manasanch
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Muhammad R Ullah
- Ameer-ud-Din Medical College, Lahore General Hospital, Lahore, Pakistan
| | - Partow Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Sheeba K Thomas
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Donna M Weber
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation & Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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184
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Biavati L, Huff CA, Ferguson A, Sidorski A, Stevens MA, Rudraraju L, Zucchinetti C, Ali SA, Imus P, Gocke CB, Gittelman RM, Johnson S, Sanders C, Vignali M, Gandhi A, Ye X, Noonan KA, Borrello I. An Allogeneic Multiple Myeloma GM-CSF-Secreting Vaccine with Lenalidomide Induces Long-term Immunity and Durable Clinical Responses in Patients in Near Complete Remission. Clin Cancer Res 2021; 27:6696-6708. [PMID: 34667029 DOI: 10.1158/1078-0432.ccr-21-1916] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/29/2021] [Accepted: 09/24/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE This proof-of-principle clinical trial evaluated whether an allogeneic multiple myeloma GM-CSF-secreting vaccine (MM-GVAX) in combination with lenalidomide could deepen the clinical response in patients with multiple myeloma in sustained near complete remission (nCR). PATIENTS AND METHODS Fifteen patients on lenalidomide were treated with MM-GVAX and pneumococcal conjugate vaccine (PCV; Prevnar) at 1, 2, 3, and 6 months. RESULTS Eight patients (53.3%) achieved a true CR. With a median follow-up of 5 years, the median progression-free survival had not been reached, and the median overall survival was 7.8 years from enrollment. MM-GVAX induced clonal T-cell expansion and measurable cytokine responses that persisted up to 7 years in all patients. At baseline, a higher minimal residual disease was predictive of early relapse. After vaccination, a lack of both CD27-DNAM1-CD8+ T cells and antigen-presenting cells was associated with disease progression. CONCLUSIONS MM-GVAX, along with lenalidomide, effectively primed durable immunity and resulted in long-term disease control, as suggested by the reappearance of a detectable, fluctuating M-spike without meeting the criteria for clinical relapse. For patients in a nCR, MM-GVAX administration was safe and resulted in prolonged clinical responses.
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Affiliation(s)
- Luca Biavati
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Carol Ann Huff
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Anna Ferguson
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Amy Sidorski
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - M Amanda Stevens
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Lakshmi Rudraraju
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Cristina Zucchinetti
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Syed Abbas Ali
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Philip Imus
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Christian B Gocke
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | | | - Xiaobu Ye
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Kimberly A Noonan
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ivan Borrello
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland.
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185
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Rodriguez-Otero P, Paiva B, San-Miguel JF. Roadmap to cure multiple myeloma. Cancer Treat Rev 2021; 100:102284. [PMID: 34597912 DOI: 10.1016/j.ctrv.2021.102284] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022]
Abstract
Despite significant advances in the treatment of multiple myeloma which had led to unprecedented rates of response and survival, patients still relapse, and cure remains elusive. We propose in this review a roadmap to achieve the dream of cure for multiple myeloma based on five complementary strategies. First, to increase knowledge about disease pathogenesis with a focus on the biology of circulating tumor cells, responsible for dissemination and extramedullary disease, and minimal residual disease clones who represent the reservoir of clonal evolution and disease recurrence. Second, to consider undetectable measurable residual disease (MRD), defined by high-sensitive techniques, as the new endpoint of therapy. Third, to treat disease causation instead of symptomatology through early detection and intervention. Thereby, by treating high-risk smoldering myeloma patients early, we may not only contribute to delay disease progression into active disease but also to increase the cure rates. Fourth, to use the most active scheme in standard-risk patients if the cure is in the horizon. Fifth, to investigate experimental therapies in newly diagnosed patients with high-risk MM, implementing early rescue intervention strategies with the goal of eradicating all tumor clones, and achieving minimal residual disease negativity.
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Affiliation(s)
- Paula Rodriguez-Otero
- Department of Hematology, Clinica Universidad de Navarra, IDISNA, Pamplona, Spain; CIBERONC CB16/12/00369, Spain
| | - Bruno Paiva
- Department of Hematology, Clinica Universidad de Navarra, IDISNA, Pamplona, Spain; CIBERONC CB16/12/00369, Spain; Centro de Investigación Médica Aplicada (CIMA), Universidad de Navarra, Pamplona, Spain
| | - Jesús F San-Miguel
- Department of Hematology, Clinica Universidad de Navarra, IDISNA, Pamplona, Spain; CIBERONC CB16/12/00369, Spain; Centro de Investigación Médica Aplicada (CIMA), Universidad de Navarra, Pamplona, Spain.
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186
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Abstract
Multiple myeloma is the second most common hematological malignancy in adults, accounting for 2% of all cancer-related deaths in the UK. Current chemotherapy-based regimes are insufficient, as most patients relapse and develop therapy resistance. This review focuses on current novel antibody- and aptamer-based therapies aiming to overcome current therapy limitations, as well as their respective limitations and areas of improvement. The use of computer modeling methods, as a tool to study and improve ligand-receptor alignments for the use of novel therapy development will also be discussed, as it has become a rapid, reliable and comparatively inexpensive method of investigation.
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187
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Suzuki K, Nishiwaki K, Yano S. Treatment Strategy for Multiple Myeloma to Improve Immunological Environment and Maintain MRD Negativity. Cancers (Basel) 2021; 13:4867. [PMID: 34638353 PMCID: PMC8508145 DOI: 10.3390/cancers13194867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023] Open
Abstract
Improving the immunological environment and eradicating minimal residual disease (MRD) are the two main treatment goals for long-term survival in patients with multiple myeloma (MM). Immunomodulatory drugs (IMiDs), monoclonal antibody drugs (MoAbs), and autologous grafts for autologous stem cell transplantation (ASCT) can improve the immunological microenvironment. ASCT, MoAbs, and proteasome inhibitors (PIs) may be important for the achievement of MRD negativity. An improved immunological environment may be useful for maintaining MRD negativity, although the specific treatment for persistent MRD negativity is unknown. However, whether the ongoing treatment should be continued or changed if the MRD status remains positive is controversial. In this case, genetic, immunophenotypic, and clinical analysis of residual myeloma cells may be necessary to select the effective treatment for the residual myeloma cells. The purpose of this review is to discuss the MM treatment strategy to "cure MM" based on currently available therapies, including IMiDs, PIs, MoAbs, and ASCT, and expected immunotherapies, such as chimeric antigen receptor T cell (CAR-T) therapy, via improvement of the immunological environment and maintenance of MRD negativity.
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Affiliation(s)
- Kazuhito Suzuki
- Department of Internal Medicine, Division of Clinical Oncology and Hematology, The Jikei University Kashiwa Hospital, Tokyo 277-8567, Japan;
- Department of Internal Medicine, Division of Clinical Oncology and Hematology, The Jikei University School of Medicine, Tokyo 105-8461, Japan;
| | - Kaichi Nishiwaki
- Department of Internal Medicine, Division of Clinical Oncology and Hematology, The Jikei University Kashiwa Hospital, Tokyo 277-8567, Japan;
- Department of Internal Medicine, Division of Clinical Oncology and Hematology, The Jikei University School of Medicine, Tokyo 105-8461, Japan;
| | - Shingo Yano
- Department of Internal Medicine, Division of Clinical Oncology and Hematology, The Jikei University School of Medicine, Tokyo 105-8461, Japan;
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188
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Ravi G, Gonsalves WI. Current diagnosis, risk stratification and treatment paradigms in newly diagnosed multiple myeloma. Cancer Treat Res Commun 2021; 29:100444. [PMID: 34555665 DOI: 10.1016/j.ctarc.2021.100444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 07/03/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Gayathri Ravi
- Division of Hematology, Mayo Clinic, Rochester MN, USA
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189
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Maintenance Strategies for Myeloma: Is Bigger Always Better? Cancer J 2021; 27:231-238. [PMID: 34549912 DOI: 10.1097/ppo.0000000000000524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Over the last decade, several very important prospective randomized controlled trials have confirmed the significant survival benefit conferred by maintenance therapies. Owing to these developments, the role of continued maintenance in the optimal management strategies of newly diagnosed myeloma patients (both transplant-eligible and transplant-ineligible) has been strongly cemented. In dealing with an incurable disease such as myeloma, whether to offer maintenance is no longer as relevant a question as it was before, but which antimyeloma agent or agents to use, as maintenance remains more pertinent today. More importantly, a personalized risk-stratified maintenance approach for an individual patient to yield the best benefit for that specific patient is yet to be uniformly adapted. In this article, we review the available and evolving clinical data leading to our current-day practices, and we make an effort to describe what lies ahead.
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190
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Ho M, Zanwar S, Kapoor P, Gertz M, Lacy M, Dispenzieri A, Hayman S, Dingli D, Baudi F, Muchtar E, Leung N, Kourelis T, Warsame R, Fonder A, Hwa L, Hobbs M, Kyle R, Rajkumar SV, Kumar S. The Effect of Duration of Lenalidomide Maintenance and Outcomes of Different Salvage Regimens in Patients with Multiple Myeloma (MM). Blood Cancer J 2021; 11:158. [PMID: 34552051 PMCID: PMC8458275 DOI: 10.1038/s41408-021-00548-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/20/2021] [Accepted: 09/02/2021] [Indexed: 12/17/2022] Open
Abstract
The optimal duration of lenalidomide maintenance post-autologous stem cell transplant (ASCT) in Multiple Myeloma (MM), and choice of therapy at relapse post-maintenance, need further evaluation. This retrospective study assessed outcomes of patients with MM (n = 213) seen at Mayo Clinic, Rochester between 1/1/2005-12/31/2016 who received lenalidomide maintenance post-ASCT. The median PFS was 4 (95% CI: 3.4, 4.5) years from diagnosis of MM; median OS was not reached (5-year OS: 77%). Excluding patients who stopped lenalidomide maintenance within 3 years due to progression on maintenance, ≥3 years of maintenance had a superior 5-year OS of 100% vs. 85% in <3 years (p = 0.011). Median PFS was 7.2 (95% CI: 6, 8.5) years in ≥3 years vs. 4.4 (95% CI: 4.3, 4.5) years in <3 years (p < 0.0001). Lenalidomide refractoriness at first relapse was associated with inferior PFS2 [8.1 (95% CI: 6.4, 9.9) months vs. 19.9 (95% CI: 9.7, 30.2; p = 0.002) months in nonrefractory patients]. At first relapse post-maintenance, median PFS2 was superior with daratumumab-based regimens [18.4 (95% CI: 10.9, 25.9) months] versus regimens without daratumumab [8.9 (95% CI: 5.5, 12.3) months; p = 0.006]. Daratumumab + immunomodulatory drugs had superior median PFS2 compared to daratumumab + bortezomib [NR vs 1 yr (95% CI: 0.5, 1.5); p = 0.004].
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Affiliation(s)
- Matthew Ho
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Saurabh Zanwar
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Martha Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suzanne Hayman
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis Baudi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eli Muchtar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amie Fonder
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lisa Hwa
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Miriam Hobbs
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert Kyle
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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191
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Baertsch MA, Fougereau M, Hielscher T, Sauer S, Breitkreutz I, Jordan K, Müller-Tidow C, Goldschmidt H, Raab MS, Hillengass J, Giesen N. Carfilzomib, Lenalidomide, and Dexamethasone Followed by Salvage Autologous Stem Cell Transplant with or without Maintenance for Relapsed or Refractory Multiple Myeloma. Cancers (Basel) 2021; 13:4706. [PMID: 34572934 PMCID: PMC8472377 DOI: 10.3390/cancers13184706] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 12/05/2022] Open
Abstract
Salvage high-dose chemotherapy and autologous stem cell transplantation (HDCT/ASCT) is a treatment option for relapsed and/or refractory multiple myeloma (RRMM). No data are available on salvage HDCT/ASCT following re-induction treatment with state-of-the-art triplet regimens. We retrospectively report on 44 patients receiving salvage HDCT/ASCT following re-induction with carfilzomib/lenalidomide/dexamethasone (KRd). All patients received frontline HDCT/ASCT with median time to progression (TTP1) of 2.9 (1.2-13.5) years, enabling paired comparison of frontline and salvage HDCT/ASCT. After re-induction and before salvage transplant, 25/44 patients (57%) attained ≥ very good partial response (VGPR), which increased to 34/44 (77%) at best response after salvage HDCT/ASCT. Median progression-free survival (PFS) was 23.3 months from salvage HDCT/ASCT. Patients with ≥ VGPR at the time of salvage HDCT/ASCT and those receiving maintenance treatment post salvage HDCT/ASCT had significantly superior PFS (hazard ratio (HR) 0.19, p = 0.001 and HR 0.20, p = 0.009). In patients achieving at least an equal depth of response before salvage HDCT/ASCT as before frontline HDCT/ASCT, PFS after salvage HDCT/ASCT was comparable to the frontline situation (p = 0.3). This is the first report of state-of-the-art triplet re-induction and salvage HDCT/ASCT for RRMM after frontline transplantation. Deep remissions achieved with KRd translate into prolonged PFS following salvage HDCT/ASCT and are enhanced by maintenance treatment.
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Affiliation(s)
- Marc-Andrea Baertsch
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
| | - Mathilde Fougereau
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center, 69121 Heidelberg, Germany
| | - Sandra Sauer
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
| | - Iris Breitkreutz
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
| | - Karin Jordan
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
| | - Carsten Müller-Tidow
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg University Hospital, 69121 Heidelberg, Germany
| | - Hartmut Goldschmidt
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg University Hospital, 69121 Heidelberg, Germany
| | - Marc-Steffen Raab
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center, 69121 Heidelberg, Germany
| | - Jens Hillengass
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
- Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA
| | - Nicola Giesen
- Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69121 Heidelberg, Germany
- Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center, 69121 Heidelberg, Germany
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Kapoor P, Kumar S. Daratumumab for post-ASCT maintenance treatment of myeloma. Lancet Oncol 2021; 22:1345-1347. [PMID: 34529932 DOI: 10.1016/s1470-2045(21)00490-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Affiliation(s)
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Moreau P, Hulin C, Perrot A, Arnulf B, Belhadj K, Benboubker L, Béné MC, Zweegman S, Caillon H, Caillot D, Corre J, Delforge M, Dejoie T, Doyen C, Facon T, Sonntag C, Fontan J, Mohty M, Jie KS, Karlin L, Kuhnowski F, Lambert J, Leleu X, Macro M, Orsini-Piocelle F, Roussel M, Stoppa AM, van de Donk NWCJ, Wuillème S, Broijl A, Touzeau C, Tiab M, Marolleau JP, Meuleman N, Vekemans MC, Westerman M, Klein SK, Levin MD, Offner F, Escoffre-Barbe M, Eveillard JR, Garidi R, Ahmadi T, Krevvata M, Zhang K, de Boer C, Vara S, Kampfenkel T, Vanquickelberghe V, Vermeulen J, Avet-Loiseau H, Sonneveld P. Maintenance with daratumumab or observation following treatment with bortezomib, thalidomide, and dexamethasone with or without daratumumab and autologous stem-cell transplant in patients with newly diagnosed multiple myeloma (CASSIOPEIA): an open-label, randomised, phase 3 trial. Lancet Oncol 2021; 22:1378-1390. [PMID: 34529931 DOI: 10.1016/s1470-2045(21)00428-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND CASSIOPEIA part 1 showed superior depth of response and significantly improved progression-free survival with daratumumab, bortezomib, thalidomide, and dexamethasone (D-VTd) versus bortezomib, thalidomide, and dexamethasone (VTd) as induction and consolidation in patients with autologous stem-cell transplant (ASCT)-eligible newly diagnosed multiple myeloma. In part 2, we compared daratumumab maintenance versus observation only. METHODS CASSIOPEIA is a two-part, open-label, randomised, phase 3 trial of patients aged 18-65 years with newly diagnosed multiple myeloma and Eastern Cooperative Oncology Group performance status 0-2, done in 111 European academic and community practice centres. In part 1, patients were randomly assigned (1:1) to induction and consolidation with D-VTd or VTd. Patients still on study who had a partial response or better were randomly assigned (1:1) by an interactive web-response system to daratumumab 16 mg/kg intravenously every 8 weeks (a reduced frequency compared with standard daratumumab long-term dosing) or observation only for up to 2 years. Stratification factors were induction treatment and depth of response in part 1. The part 2 primary endpoint was progression-free survival from second randomisation. This preplanned interim analysis of progression-free survival was done after 281 events and shall be considered the primary analysis of progression-free survival. Sponsor personnel and designees who were involved in the analysis were masked to treatment group until the independent data monitoring committee recommended that the preplanned interim analysis be considered the main analysis of progression-free survival in part 2. Otherwise, treatment assignments were unmasked. The interaction between induction and consolidation and maintenance was tested at a two-sided significance level of 0·05 by a stratified Cox regression model that included the interaction term between maintenance treatment and induction and consolidation treatment. Efficacy analyses were done in the maintenance-specific intention-to-treat population, which comprised all patients who underwent second randomisation. Safety was analysed in all patients in the daratumumab group who received at least one dose and all patients randomly assigned to observation only. This trial is registered with ClinicalTrials.gov, NCT02541383. Long-term follow-up is ongoing and the trial is closed to new participants. FINDINGS Between May 30, 2016, and June 18, 2018, 886 patients (458 [84%] of 543 in the D-VTd group and 428 [79%] of 542 in the VTd group) were randomly assigned to daratumumab maintenance (n=442) or observation only (n=444). At a median follow-up of 35·4 months (IQR 30·2-39·9) from second randomisation, median progression-free survival was not reached (95% CI not evaluable [NE]-NE) with daratumumab versus 46·7 months (40·0-NE) with observation only (hazard ratio 0·53, 95% CI 0·42-0·68, p<0·0001). A prespecified analysis of progression-free survival results showed a significant interaction between maintenance and induction and consolidation therapy (p<0·0001). The most common grade 3 or 4 adverse events were lymphopenia (16 [4%] of 440 patients in the daratumumab group vs eight [2%] of 444 patients in the observation-only group), hypertension (13 [3%] vs seven [2%]), and neutropenia (nine [2%] vs ten [2%]). Serious adverse events occurred in 100 (23%) patients in the daratumumab group and 84 (19%) patients in the observation-only group. In the daratumumab group, two adverse events led to death (septic shock and natural killer-cell lymphoblastic lymphoma); both were related to treatment. INTERPRETATION Daratumumab maintenance every 8 weeks for 2 years significantly reduced the risk of disease progression or death compared with observation only. Longer follow-up and other ongoing studies will shed further light on the optimal daratumumab-containing post-ASCT maintenance treatment strategy. FUNDING Janssen Research & Development, the Intergroupe Francophone du Myélome, and the Dutch-Belgian Cooperative Trial Group for Hematology Oncology.
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Affiliation(s)
- Philippe Moreau
- Hematology Clinic, University Hospital Hôtel-Dieu, Nantes, France.
| | - Cyrille Hulin
- Bordeaux University Hospital Center, Bordeaux, France
| | - Aurore Perrot
- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Bertrand Arnulf
- Hematology and Oncology, Hôpital Saint Louis, APHP, Paris, France
| | | | | | - Marie C Béné
- Hematology Biology, Nantes University Hospital, Nantes, France
| | - Sonja Zweegman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Hélène Caillon
- Biochemistry Laboratory, Nantes University Hospital, Nantes, France
| | - Denis Caillot
- Dijon University Hospital, Hôpital du Bocage, Dijon, France
| | - Jill Corre
- Unité de Genomique du Myélome, IUC-T Oncopole, Toulouse, France
| | - Michel Delforge
- Department of Hematology, University Hospital Leuven, Leuven, Belgium
| | - Thomas Dejoie
- Biochemistry Laboratory, Nantes University Hospital, Nantes, France
| | - Chantal Doyen
- Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Thierry Facon
- Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France
| | - Cécile Sonntag
- University Hospital, Hôpital Hautepierre, Strasbourg, France
| | - Jean Fontan
- University Hospital Jean Minjoz, Besancon, France
| | - Mohamad Mohty
- Hematology and Cellular Therapy Department of Saint-Antoine Hospital, Sorbonne University, Paris, France
| | | | - Lionel Karlin
- Lyon University Hospital, Hematology Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | | | | | - Xavier Leleu
- Poitiers University Hospital, CHU la Milétrie, Poitiers, France
| | | | | | | | | | | | - Soraya Wuillème
- Hematology Biology, Nantes University Hospital, Nantes, France
| | | | - Cyrille Touzeau
- Hematology Clinic, University Hospital Hôtel-Dieu, Nantes, France
| | - Mourad Tiab
- Centre Hospitalier Départemental Vendée, La Roche sur Yon, France
| | | | - Nathalie Meuleman
- Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | | | | | | - Réda Garidi
- Saint-Quentin Hospital Center, Saint Quentin, France
| | | | | | - Ke Zhang
- Janssen Research & Development, La Jolla, CA, USA
| | - Carla de Boer
- Janssen Research & Development, LLC, Leiden, Netherlands
| | - Sanjay Vara
- Janssen Research & Development, High Wycombe, UK
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194
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Fei F, Reddy V, Rosenblum F. Secondary primary malignancies in patients with multiple myeloma: A single institution experience. Hematol Oncol 2021; 39:674-679. [PMID: 34510500 DOI: 10.1002/hon.2923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/25/2021] [Accepted: 08/25/2021] [Indexed: 01/22/2023]
Abstract
The purpose of our study is to highlight the demographic characteristics, pathological features, and clinical course of multiple myeloma (MM) patients with secondary primary malignancies (SPM). A retrospective chart review was performed from January 2009 to February 2020. Patients' demographic, pathologic and cytogenetic features, treatment characteristics and clinical outcomes were collected. We identified 871 MM patients including 40 patients who developed SPM. Among the 40 patients with SPM, 17 patients developed hematological SPM and 23 patients developed solid SPM. The median time from diagnosis of MM to the occurrence of hematological SPM was 6.85 versus 3.91 years in solid SPM, with a median overall survival (OS) after diagnosis of SPM of 120 and 880 days, respectively. Interestingly, we observed that there was no significant difference in OS between MM patients with or without SPM. Multivariable analysis showed that age and autologous stem cell transplantation were independent factors associated with patients' clinical outcomes. Our study highlights the importance of understanding the etiology, biology, clinical outcome and management in MM patients with SPM.
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Affiliation(s)
- Fei Fei
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vishnu Reddy
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Frida Rosenblum
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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195
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Nivolumab Effective for Gastric and Lung Cancers but Not for Multiple Myeloma in a Multiple Primary Cancer Patient. Case Rep Hematol 2021; 2021:9965371. [PMID: 34484843 PMCID: PMC8416369 DOI: 10.1155/2021/9965371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
The case of a 76-year-old man with multiple primary cancers that were treated with nivolumab is presented. Six years earlier, he was diagnosed with multiple myeloma (MM) and was treated with several chemotherapies. He was also diagnosed with gastric cancer with liver metastasis and primary lung cancer by upper gastrointestinal endoscopy and computed tomography (CT). Nivolumab treatment was given as third-line therapy, and it was effective for gastric and lung cancers. But MM worsened, and the patient died. There is no standard treatment for multiple primary cancers, and the development of effective treatments for multiple primary cancers is important.
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196
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Gorin NC. History and Development of Autologous Stem Cell Transplantation for Acute Myeloid Leukemia. Clin Hematol Int 2021; 3:83-95. [PMID: 34820613 PMCID: PMC8486970 DOI: 10.2991/chi.k.210703.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
This review describes the development of cryopreservation, the birth of autologous stem cell transplantation (ASCT) and its past and present use to consolidate adult patients with acute myelogenous leukemia (AML). It summarizes the first autografts in patients in relapse, the experience of autografting in complete remission (CR), using bone marrow unpurged or purged in vitro with cyclophosphamide-derivatives, and the important shift to peripheral blood stem cells. The review also discusses the results of recent studies in favor of the use of ASCT to consolidate good- and intermediate-risk patients who reach CR with no detectable minimal residual disease, and those which support the inclusion of maintenance therapy post autograft with hypomethylating agents, anti-BCL-2, and, possibly, in the future, anti AML chimeric antigen receptor-T cells. Carefully applied to well-selected patients, ASCT may regain interest, because of its simplicity, its reduced toxicity, lower non-relapse mortality and better quality of life.
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Affiliation(s)
- Norbert Claude Gorin
- Department of Hematology and Cell Therapy, and EBMT Global Committee, Hopital Saint-Antoine APHP, Paris Sorbonne University, Paris, France
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197
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Derman BA, Kosuri S, Jakubowiak A. Knowing the unknowns in high risk multiple myeloma. Blood Rev 2021; 51:100887. [PMID: 34479756 DOI: 10.1016/j.blre.2021.100887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/28/2022]
Abstract
High risk multiple myeloma (HRMM) continues to portend worse outcomes despite the many advances in anti-myeloma therapeutics. The optimal approach to treatment is not clearly defined on account of the variable definitions of HRMM and the paucity of studies dedicated to the treatment of HRMM. In this review, we use a case-based approach to review the definitions of HRMM, and evaluate the evidence for induction, stem cell transplantation, and post-transplant therapy approaches for HRMM.
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Affiliation(s)
- Benjamin A Derman
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, United States of America.
| | - Satyajit Kosuri
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, United States of America
| | - Andrzej Jakubowiak
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, United States of America
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198
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Miles B, Mackey JD. Increased Risk of Second Primary Malignancy and Mortality at ten Years After Stem Cell Transplant for Multiple Myeloma: An Analysis of 14,532 Patients. Cureus 2021; 13:e16372. [PMID: 34422458 PMCID: PMC8366185 DOI: 10.7759/cureus.16372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background The landscape for patients with multiple myeloma has improved dramatically over the last 15 years. Immunomodulatory imide drugs (IMiDs) have shown great efficacy in both the setting of initial therapy and as maintenance after autologous stem cell transplant (ASCT). Concern has arisen, however, regarding the risk of second primary malignancies (SPMs) that appear to be associated with the use of IMiD agents. SPMs are a known sequela of multiple myeloma treatment, particularly as a consequence of maintenance lenalidomide status-post stem cell transplant (SCT). The benefit of SCT has become less clear with the utilization of newer, more effective initial therapies. Objectives To determine the effect of SCT on SPM risk and overall survival in multiple myeloma patients at 5 and 10 years after treatment initiation. Methods We used TriNetX, a global federated health research network providing access to electronic medical records (diagnoses, procedures, medications, laboratory values, genomic information) from approximately 58 million patients in 49 large healthcare organizations. We created two patient cohorts who had all received treatment with thalidomide, lenalidomide, or pomalidomide. One cohort had received SCT while the other had not. Both cohorts were then analyzed for the development of all non-myeloma malignancies which occurred at least one year after initiation of treatment. Results At 5 years, SPMs were 5.8% more likely in patients who received stem cell transplant (22.4% vs 16.6%, RR 0.741, p value <0.0001) but 5-year survival favored transplanted patients by 2.38% (64.85% vs 62.474%, p value 0.0044). 10-year survival favored patients who did not receive transplant by 1.44% (42.279% vs 40.838%, p value 0.0279). The Kaplan-Meier curves cross at year 6. Conclusions It has previously been shown that the use of alkylating agents in myeloma patients significantly increases the risk of SPM, but that difference had curiously not been shown to have a negative impact on survival. Our analysis shows that this negative survival impact does exist but requires six or more years of follow up to become evident. Recent analyses from studies using older regimens show no overall survival benefit from the use of stem cell transplant. As non-transplant regimens become more effective at producing minimal residual disease (MRD) negativity, it seems that transplantation for myeloma patients will soon be regarded as unnecessary or even detrimental.
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Affiliation(s)
- Brittany Miles
- Medical Education, University of Texas Medical Branch, Galveston, USA.,Radiology, University of Texas Medical Branch, Galveston, USA
| | - James D Mackey
- Medical Oncology, Baylor University Medical Center, Dallas, USA
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199
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Suzuki K, Min CK, Kim K, Lee JJ, Shibayama H, Ko PS, Huang SY, Li SS, Ding B, Khurana M, Iida S. Carfilzomib, dexamethasone, and daratumumab in Asian patients with relapsed or refractory multiple myeloma: post hoc subgroup analysis of the phase 3 CANDOR trial. Int J Hematol 2021; 114:653-663. [PMID: 34410635 DOI: 10.1007/s12185-021-03204-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Due to increasing use of frontline lenalidomide, effective and safe lenalidomide-free therapies for relapsed/refractory multiple myeloma (RRMM) are needed in Asia. This subgroup analysis of phase 3 CANDOR study evaluated efficacy and safety of KdD vs Kd in Asian patients with RRMM. METHODS Self-identified Asian patients with RRMM (KdD = 46; Kd = 20) with 1‒3 prior therapies were included. The primary endpoint of progression-free survival was estimated by stratified Cox regression. RESULTS Baseline demographics and patient characteristics were balanced in both arms. KdD reduced the risk of progression or death by 25% vs Kd [hazard ratio (HR) = 0.75; 95% CI 0.259, 2.168] in the Asian subgroup, compared with 37% vs Kd (0.63; 0.464, 0.854) in the overall CANDOR population. Percentage of patients who reported grade ≥ 3 treatment-emergent adverse events (TEAEs) in the KdD and Kd arms was 95.7 and 90.0%, respectively. Serious AEs were observed in 58.7 and 40.0% of patients in the KdD and Kd arms, respectively. There were two (4.3%) fatal TEAEs in the KdD arm due to infections. CONCLUSIONS There was a trend toward better efficacy and a favorable benefit-risk profile for KdD vs Kd in Asian patients with RRMM. Cautious interpretation is warranted due to small patient size.
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Affiliation(s)
- Kenshi Suzuki
- Department of Hematology, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, Japan.
| | - Chang-Ki Min
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Kihyun Kim
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Jeollanam-do, South Korea
| | - Hirohiko Shibayama
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Po-Shen Ko
- Faculty of Medicine, National Yang-Ming University, Taipei City, Taiwan.,Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Shang-Yi Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei City, Taiwan
| | - Sin-Syue Li
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | | | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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200
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Mann H, Katiyar V, Varga C, Comenzo RL. Smoldering multiple myeloma - Past, present, and future. Blood Rev 2021; 52:100869. [PMID: 34312016 DOI: 10.1016/j.blre.2021.100869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023]
Abstract
Smoldering multiple myeloma (SMM) routinely precedes the development of multiple myeloma. While some patients experience aggressive disease, others have more indolent courses akin to those with monoclonal gammopathy of undetermined significance. Much effort has been made to understand the pathobiological basis of this heterogeneity. Scientific advancements have led to the emergence of various clinical and genomic markers of relevance, translating into evolution of disease definitions over time. More recently, the interest in manipulation of biological pathways has intensified in a bid to stall or halt disease progression. Studies with lenalidomide have exemplified the promise of early intervention, whereas numerous therapeutic approaches remain the subject of ongoing clinical investigation. This review summarizes the historic progress made in defining SMM as a distinct clinicopathologic entity, provides a critical appraisal of the evidence guiding risk assessment, and suggests a pragmatic approach to its modern-day management. Finally, an overview of developments on the horizon is also provided.
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Affiliation(s)
- Hashim Mann
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA; The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.
| | - Vatsala Katiyar
- Division of Hematology/Oncology, Brown Cancer Center, University of Louisville, Louisville, KY, USA
| | - Cindy Varga
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA; The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| | - Raymond L Comenzo
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA; The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
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